Career Opportunities

Health Home Care Manager


Reporting: Health Home Care Manager
Date Created: October 2022
Job Type: Sr. Manager, Direct Care Management


Candidates should submit resumes to [email protected]

Position Summary

Provide care management services working with clients in the community and in collaboration with providers and clients’ care team. Proactively manage the needs of clients with high risk or complex medical, behavioral health and/or psychosocial needs through community and home-based visits and telephonic support. Develop and implement a care management plan based on client assessment, goals, preferences and disease states to promote improved health care outcomes and quality of life. Link clients to appropriate community resources, facilitate referral to appropriate care
services, support client self-management, and communicate with providers to reduce barriers to improved health care outcomes. Maintain written documentation meeting NYSDOH, Managed Care Organizations (MCOs), GRHHN, and other applicable requirements for appropriate billing and clinical interventions.


  • Bachelor’s degree or equivalent experience.
  • 5 – 7 years’ experience of workforce development, preferably in a non-profit or healthcare sector.
  • Knowledge of workforce trends to effectively support workforce programs.
  • Advanced skills in Microsoft Office applications including Excel, PowerPoint, and Word.


  • Contact potential and referred clients within appropriate time frame, addressing any urgent emergent issues and scheduling in-person assessment.

  • Engage clients to enable intervention and support; obtain appropriate consent to share information signed by the client or caregiver/ authorized representative.
  • Conduct an assessment of client condition, needs, preferences and clinical and psychosocial barriers, collecting information from clients and their families and caregivers with client consent.

  • Identify risk of adverse health outcomes (e.g. death, disability, inpatient admission, SNF admission or ED visit).
  • Develop a care management plan based on the client’s goals, strengths and barriers that promote improved health care outcomes and quality of life.

  • Maintain contact with the client at appropriate frequency to meet the acuity and/or complexity of the client’s current needs, condition or situation.
  • Address the unique needs and provide required services to clients who are members of special populations (e.g. Health and Recovery Plan (HARP) members, children, those qualifying for Health Home Plus, etc.)

  • Provide feedback to providers regarding client progress and barriers encountered

  • Review client plan of care progress no less frequently than semi-annually

  • Modify goals and care management interventions as appropriate to the needs/progress of the individual

  • Share information (e.g. progress, barriers, new conditions, etc.) between Team members and other care providers

  • Implement the client approved plan of care in collaboration with the care team and client:
  • Provide culturally sensitive self-management support, health promotion, connection/referral to appropriate providers and community-based organizations to decrease barriers to following the plan of care
  • Utilize Self-Management Support interventions to promote self-advocacy.
  • Monitor the client’s level of engagement relative to their health goals over time.
  • Advocate for clients to assure access and timely service delivery across the continuum of care and community resources.
  • Provide education/ information to clients/caregivers in support of care plan goals.
  • Optimize insurance and other benefits to support client access to needed services.
  • Provide care coordination with Primary/Specialty Medical care, acute and outpatient medical, mental health and substance abuse services, and other care managers involved in supporting the individual

  • Provide comprehensive transitional care to coordinate care and services post critical events (i.e. emergency department use, hospital inpatient admission and discharge, residential facility or skilled nursing facility admission and discharge)

  • Provide crisis intervention planning to address events such as emergency department visits, inpatient admissions or other crisis events to ensure planned crisis interventions are effective. Make necessary modifications to the Plan of Care

  • Conduct medication reconciliation as appropriate and communicate needs for adjustments to care team/provider

  • Work with family regarding the client’s needs; assess caregiver’s burdens; provide family and caregiver support; ensure language access/translation services


  • Ability to interact with external Partners and staff (at all levels) in a fast-paced environment, sometimes under pressure, remaining positive, flexible, proactive, resourceful and efficient, with a high level of professionalism that is crucial in this role
  • Initiative and the ability to effectively participate in an environment in which collaboration is highly valued and reporting relationships are not direct; possess a flexible, “can-do” attitude
  • Highly organized and strong attention to detail with the ability to effectively manage own time and the time of others
  • Excellent written and oral presentation skills, with the ability to engage, inspire, build credibility and engender trust across all levels of an organization
  • Creative problem-solving skills
  • Team player but can also work on own initiatives independently
  • Outstanding discretion in handling of Protected Health Information, financial and other confidential information
  • Ability to approach daily work and challenging situations with humor and composure
  • Consistent demonstration of FLPPS Personality traits: Collaborative, Trusted, Result-Oriented, Strategic and Adaptive

In support of the American with Disabilities Act (ADA), this job description lists those responsibilities and qualifications deemed essential to the position. This job description is a summary of the typical functions of the job, and additional responsibilities may be assigned as necessary.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender, gender identity or expression, sexual orientation, national origin, marital status, genetics, disability, age, veteran status, or any other legally protected status.

FLPPS is committed to providing service that is culturally and linguistically appropriate for our diverse partnerships. We work to ensure that our philosophy of cultural and linguistic diversity is embraced in all levels of our organization. Culturally competent services are required from both our employees and our partners.